Provider Demographics
NPI:1770638702
Name:MAINLINE CPL, LLC
Entity Type:Organization
Organization Name:MAINLINE CPL, LLC
Other - Org Name:MAINLINE PHARMACY PORTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:619 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1539
Mailing Address - Country:US
Mailing Address - Phone:814-736-4530
Mailing Address - Fax:814-736-9522
Practice Address - Street 1:619 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-1539
Practice Address - Country:US
Practice Address - Phone:814-736-4530
Practice Address - Fax:814-736-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413275L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007331830002Medicaid